The proposal is a feasibility study that pilot tests a methodology to quantify nursing home medical staff organization (NHMSO) and its impact on relevant health care outcomes. Aim I. Construct and pilot test a reliable and valid instrument to measure nursing home medical staff organizational (NHMSO) structure. The NHMSO scale will be developed using input from focus groups and cognitive interviews with experts from the American Medical Directors (AMDA) Research Network. The scaled instrument will be piloted with a random sample of medical directors from AMDA, who represent freestanding nursing facilities. Standard survey techniques will be used (Dilman) with a 10% data check to ensure accuracy of responses entered into the database. Reliability, exploratory factor analysis, and tests for convergent and discriminant validity will be conducted. To further refine and enhance the instrument, a Medical director and administrator self-report will be compared to external observational data on a 1/3 sub-sample of the facilities from the pilot; this will allow the calculation of convergent validity and method variance. Aim II. Initiate a feasibility study of the NHMSO survey instrument using an expanded random sample of medical directors from freestanding facilities drawn from the American Medical Directors Association (AMDA) membership. The feasibility and generalizability of the survey will be determined by calculating response rates as well as cross validation and sub-group analyses. Aim Ill. Implement a pilot study to examine clinical care outcomes associated with NHMSO patterns. The survey results will be merged to available nursing home data (Nursing Home Compare and OSCAR). Multivariate regression techniques, adjusting for confounding facility characteristics, will examine the hypothesized association of NHMSO with the previously defined quality of care metrics. Results of this study and its framework will guide future projects to explore the relationship between medical structure, medical practice patterns and health care outcomes.